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Federal Highway Administration
1200 New Jersey Avenue, SE
Washington, DC 20590
202-366-4000

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U.S. Department of Transportation/Federal Highway AdministrationU.S. Department of Transportation/Federal Highway Administration

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U.S. Department of Transportation
Federal Highway Administration		 RECORD OF AUTHORIZATION TO PROCEED WITH MAJOR CONTRACT REVISION
PROJECT NO.
 		COUNTYSTATE
TYPE OF REVISION
check box CHANGE ORDER
check box WORK ORDER		 check box SUPPLEMENTAL AGREEMENT
check box OTHER:		 check box TIME EXTENSION check box SPECIFICATION CHANGE
REQUESTED BY
 		DATE
NATURE OF AND REASON FOR PROPOSED REVISION (If additional space is required, use reverse side)
ESTIMATED
check box INCREASE
check box DECREASE		 IN COST: $ _________
METHOD OF PAYMENT
check box FORCE ACCOUNT
check box UNIT BID PRICES		 check box NEGOTIATED PRICE
check box OTHER:		 check box LUMP SUM
THE WORK COVERED BY THE PROPOSED REVISION AS DESCRIBED ABOVE IS HEREBY AUTHORIZED SUBJECT TO THE CONDITIONS MARKED BELOW:
check box EVALUATION OF COST DATA
check box LIMITATIONS OF EXTENT OF FEDERAL PARTICIPATION
check box DETERMINATION OF SATISFACTORY ADJUSTMENT IN TIME
check box ADEQUATE SUBMITTAL OF WRITTEN SUPPORTING DATA 		check box PROPOSED REVISION AUTHORIZED WITHOUT FEDERAL PARTICIPATION
check box OTHER (Explain)
check box NONE
RECOMMENDED BY AREA ENGINEER DIVISION OFFICE APPROVAL
SIGNATURE

 

 DATE SIGNATURE DATE

Form FHWA-1365 (Use Reverse for Comments, if Required)
(Rev. 3-86) PREVIOUS EDITIONS MAY BE USED

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Updated: 06/27/2017
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Federal Highway Administration | 1200 New Jersey Avenue, SE | Washington, DC 20590 | 202-366-4000